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Anesthesia Considerations for Insertion of the Peritoneal Dialysis

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Anesthesia Considerations for Insertion of the Peritoneal Dialysis ISSN: 2572-3286 Liu et al. J Clin Nephrol Ren Care 2017, 3:028 DOI: 10.23937/2572-3286.1510028 Volume 3 | Issue 2 Journal of Open Access Clinical Nephrology and Renal Care RESEARCH ARTICLE Anesthesia Considerations for Insertion of the Peritoneal Dialysis Catheter Xihui Liu1, Xiaoyan Zuo1, Xueyuan Heng1, Zita Abreu2, Todd Penner3, Lashmi Venkatraghavan4 and Joanne M Bargman2* 1Department of Nephrology, Linyi People’s Hospital, China 2Department of Nephrology, Toronto Western Hospital, University Health Network, University of Toronto, Canada 3Division of Surgery, University of Toronto, Canada 4Department of Anesthesia, University of Toronto, Canada *Corresponding author: Joanne M Bargman, Department of Nephrology, Toronto Western Hospital, University Health Network, University of Toronto, 200 Elizabeth Street, 8N-840, Toronto, Ontario M5G 2C4, Canada, Tel: 416-340-4804, E-mail: [email protected] Abstract Pressure (SBP) in the two groups at the beginning of the anesthesia, but during the surgery, the SBP of GA group Background: Laparoscopy is an effective method of im- decreased. There were no significant differences of SPO2 plantation for Peritoneal Dialysis (PD) catheters. Howev- between the two groups. The mean operating time and ob- er, in many centers around the world, Peritoneal Dialysis servation time in the Post-Anesthesia Care Unit (PACU) of Catheter (PDC) insertions are done using an open surgical the GA group was longer. After arrival in the PACU, the method, associated with greater surgical trauma and longer PACU score in GA group was lower than LA group, but there duration of hospitalization. One of the major drawbacks to was no difference between the two groups at discharge. the acceptance of laparoscopic insertion is the perceived necessity for General Anesthesia (GA) for this procedure. Conclusions: Both local and general anesthesia for lapa- In this study, we have examined methods of anesthesia roscopic catheter implantation is safe and effective. Older for laparoscopic insertion of PD catheters at a major North patients, abdominal (as opposed to pre-sternal) exit sites, American center. co-morbidity with diabetes mellitus, and those with higher ASA grade do well with local anesthesia. Methods: This retrospective study includes 245 patients with laparoscopic PD catheter insertion from January 2008 Keywords to July 2013 at the University Health Network in Toronto. The patients were consigned to Local Anesthesia (LA) and Laparoscopic insertion, Peritoneal dialysis catheter, Local General Anesthesia (GA) depending on their co-morbidity anesthesia, General anesthesia, Conscious sedation and risk assessment. The LA patients were given intra- venous conscious sedation with midazolam, fentanyl and Introduction propofol. Hemodynamic fluctuations were managed with small doses of vasopressors or vasodilators during the pro- Peritoneal Dialysis (PD) is becoming increasing- cedure. Nitrous oxide and carbon dioxide pneumoperitone- ly popular and different types of surgical techniques um were used for LA group and GA group respectively. (open, percutaneous, and laparoscopic) have been de- Results: The age, the exit site position of the catheter, the veloped for catheter placement [1]. Open surgery and history of abdominal surgery and co-morbidities such as di- especially the percutaneous technique are associated abetes and cardiovascular disease in the two groups were with poor outcomes and sometimes life-threatening significantly different. complications. In fact, the incidence of omental wrap- All patients tolerated the procedure well. Nearly 45% of the ping, catheter displacement, and intra-abdominal com- patients were given LA, there were more ASA grade IV pa- tients in this group. Ten patients were converted to GA from plications, specifically bowel and bladder perforation, is LA. There were no significant differences in Systolic Blood higher with these two methods [2]. Citation: Liu X, Zuo X, Heng X, Abreu Z, Penner T, et al. (2017) Anesthesia Considerations for Insertion of the Peritoneal Dialysis Catheter. J Clin Nephrol Ren Care 3:028. doi.org/10.23937/2572- 3286.1510028 Received: July 25, 2017: Accepted: August 30, 2017: Published: September 01, 2017 Copyright: © 2017 Liu X, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Liu et al. J Clin Nephrol Ren Care 2017, 3:028 • Page 1 of 5 • DOI: 10.23937/2572-3286.1510028 ISSN: 2572-3286 Laparoscopic implantation of PD catheters has been before discharge from the operating room, duration of shown to have advantages such as less surgical trauma operation, PACU scores at arrival and discharge respec- and decreased formation of adhesions [3,4]. Catheters tively, and observation time in PACU. At the same time, placed by laparoscopic methods have also been report- the most recent laboratory blood tests before the sur- ed to have the best outcomes [5]. The keys to successful gery were also been collected (such as hemoglobin, se- long-term PD catheter functioning after implantation rum albumin, creatinine and Creatinine Clearance (Ccr) are visual confirmation of proper catheter location and as a measure of renal function. All the patients were di- configuration during the implantation process [6]. Lap- vided into Local Anesthesia (LA) and General Anesthesia aroscopy, in addition, provides a relatively noninvasive (GA) groups. method to fully investigate the peritoneal cavity [7,8]. As a result, laparoscopy is becoming a preferential ap- Anesthesia and surgical technique proach in a growing number of centers. All procedures were performed in the operating However, in China and many other countries, near- room with an anesthesiologist in attendance. After ar- ly all Peritoneal Dialysis Catheter (PDC) insertions are rival in the operating room, an Intravenous (IV) cathe- done using an open surgical method. One of the major ter and all standard monitors (electrocardiogram, non drawbacks to the acceptance of laparoscopic insertion invasive blood pressure, pulse oximetery) were applied is the perceived necessity for General Anesthesia (GA), to the patient. Patients undergoing general anesthesia because insufflation of gas into the abdominal cavity were induced with IV propofol (1-2 mg.kg-1), fentanyl produces peritoneal pain. Given that candidates for PD (1-2 µg.kg-1), and cisatracurium (0.15 mg.kg-1) for tra- catheter implantation are patients with end-stage renal cheal intubation. The maintenance of anesthesia was failure who often have severe coexisting medical prob- with oxygen; air with either sevoflurane or desflurane lems that put them in a high-risk category for general (titrated to age adjusted Minimum Alveolar Concentra- anesthesia [9], the feasibility of laparoscopic implanta- tion (MAC) 0.8-1.1). For patients undergoing procedure tion of PDC under local is worthy of investigation. under LA, sedation was started after the application of the monitors. This consisted of midazolam 0.015 mg/ In order to promote acceptance of laparoscopy, we kg, fentanyl 1-2 ug/kg (and/or) remifentanil (0.01-0.1 have examined anesthesia for laparoscopic insertion of µg.kg-1.min-1) followed by propofol (intermittent bolus PD catheters at a major North American center. of 10-20 mg or continuous infusion at 25-150 µg.kg-1. Patients and Methods min-1), titrated to titrated to the assessment of alert- ness/sedation (OAA/S) scale 3 or 4. All patients in the LA This is a retrospective analysis. Between January group received supplemental oxygen via facemask. He- 2008 and July 2013, 245 consecutive adult patients with modynamic fluctuations were managed with small dos- renal failure underwent laparoscopic placement of peri- es of vasopressors or vasodilators during the procedure. toneal dialysis catheters at Toronto General Hospital have been enrolled. All the laparoscopic PD catheter implantations were done by one designated experienced general surgeon, All the patients were referred from the nephrology Local anesthesia was achieved by infiltrating the soft clinic to an experienced surgeon in the general surgery tissue and peritoneum with 1% lidocaine. Nitrous Ox- clinic for careful examination before being decided ide (N O) and Carbon Dioxide (CO ) pneumoperitoneum whether they are the good candidates for laparoscopic 2 2 were used for LA group and GA group respectively, in- placement of PDC. The choice of anesthetic technique flating to a maximum pressure of 12 mmHg. After com- (LA or GA) was determined in consultation with anes- pletion of the surgery, patients were transported first to thesiologist upon looking at different factors including the post-anesthesia care unit. age of the patient, associated medical co-morbidity, pa- tient cooperation, prior abdominal surgery and exit site Statistics location of the PDC. Data are expressed as mean ± standard deviation We accessed the electronic patient records, the or as number of patients. Parametric data were ana- patient charts, the operation records, the anesthet- lyzed using the independent samples t-test. For cate- ic records, and the PACU (Post-Anesthesia Care Unit) gorical data analysis, the chi-square or Fisher exact test records. Collected data for this study included demo- was used. A binary logistic regression model was used graphic data and clinical details, including the patients’ to identify the decisive factors of LA patient selection.
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